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Hey there, super friends! So far, we've managed to settle down into a groove with this whole blog thing with some solid posts about tough, challenging, weirdo, what-the-heck style procedures. Together, we've made our way through thoracotamies, Blakemores, and lateral canthotomies. We're bigger men and women in white as a result.

So, I think we're ready to tackle the elephant in the room. We're ready to battle Voldemort; we're willing to stop Johnny from "sweeping the leg"; we're going to confront the Emperor, and we will NOT turn to the dark side of the Force. Our archnemesis is calling, and we're not afraid.

That's right guys, we're doing the cric today.

Most providers I've talked to can count the number of cric's they've had in their career on one hand, but they remember every single, bloody detail of theirs, and will continue to do so until the day they die. And I'm not being glib there. The cases that lead to crics are always insanely unique; so unique that writing about any of my examples will surely open the medicolegal Pandora's box from hell. I'll abstain.

Remember your indications, mainly that you cannot oxygenate or ventilate. If you can't get the tube, but you can successfully place something temporary like an LMA, step back for a second. If there's an alternative, take it.

Anyway, just like many other things in medicine, there is more than one way to skin a cat. We will talk of a few, but not all, of the methods here, starting with the most rudimentary.

1.) Traditional Cric.

The motto of this one is: keep it simple, stupid! You need your knife, you need your hook, you need your dilator, and you need some sort of tube (either a nice trach or a sawed off 6.0 ETT). That's it!

1.) Find the cricothyroid membrane.2.) Cut skin vertically 2-3cm--get ready for some bleeding to screw up your view!3.) Cut membrane horizontally.4.) Get your hook in the superior aspect before you remove your scalpel. Also get someone to hold traction on this!5.) Get your dilator in laterally and rotate it down 90 degrees (the Trousseau's are kind of counter intuitive--squeezing opens them).6.) Tube in, cuff up, start bagging.

In terms of incision the skin, there is a bit of discrepancy between our generally accepted way of doing these and what is done in the surgery world (i.e., vertically vs. horizontally). I personally remember taking ATLS and having an older trauma surgeon laugh hysterically in my face when I demonstrated doing the initial incision vertically on a model. Ignore the haters out there, this is how we do it and that's that.

Here's a very nice demonstration on a cadaver courtesy of the University of Maryland Department of Emergency Medicine:

2.) Seldinger Cric (aka "Melkering It").

I have never seen this one done but I love the sound of it. For one, my fear of a horribly bloody surgical field is alleviated. However, this option requires a good, confident ability to locate the membrane--this might be a problem if there's significant trauma.

The kits are as simple as you'd want them to be, including your scalpel, wire, 6 mL syringe, 18 G needle w/catheter, cuffed catheter, and dilator.

Identify your landmarks, and come at the cricothyroid membrane directed 45 degrees caudad. You'll want to have your syringe loaded with a bit of saline so you can confirm entry into the trachea with air bubbles. Thread your catheter, and the rest is just as you'd expect it--wire it, incise it, and then dilate it! Your dilator slides into the catheter, and you'll want to grip them like so as you push them in:

After you've hubbed it, pull out the dilator and guidewire. You should be good to go. Here's an incredibly dated looking video from Cook Critical Care:

3.) Bougie Cric.

It's all the rage! There's a lot of buzz about this one, and rightfully so--some initial data has shown that it is related to higher success rates and less risk of tracheal damage. And it's quicker!

You need even less for this one. Your kit will include a No. 20 scalpel, a bougie, a 6.0 ETT, and your finger (you could throw in a hook as well but it's not required).

The procedure: make a horizontal stab with the scalpel at the cricothyroid membrane (yes I realize what I said earlier). Do it all the way through the skin and the membrane. Bluntly dissect down with your finger, keeping it in there. Load the bougie in under your finger. Slide the tube in. Bougie out.Done!

4.) Crazy MacGyver Cric.

We're entering the world of the unknown on this one, but essentially you resort to this when you're patient is crashing and you essentially have to grab whatever is nearby.

While I in no way shape or form recommend you try this, the ever brilliant Dr. Whit Fisher has an awesome technique for making a trach needle out of an IV spike (who would have known?):

Just threw it in for the sheer awesomeness of it all.

Pick your poison, but get it right. Practice makes perfect, and the more times you can simulate a cric, the more comfortable you will be when your number comes up. Academic Life in Emergency Medicine has a fantastic recipe to make a bleeding model for simulation.

As always, these wannabe instruction manuals are made for EDUCATIONAL PURPOSES ONLY. You already know darn well enough that a cric is the last-ditchiest of last-ditch procedures, so don't go getting heroic on us after this one.